Mortal Lessons

HSPH faculty confront a uniquely american scourge

by Harriet Washington

"There is convincing evidence, particularly from the Centers for Disease Control, that tells us that the United States may be a more violent society than all other industrialized countries," says Professor Felton Earls, director of the Project on Human Development in Chicago Neighborhoods. Two million Americans are beaten, knifed, shot, or raped every year. Of the 145,000 annual Americans deaths due to injury, at least 56,000 are due to violence; 1991, the year the CDC announced that murder was epidemic in this country, saw 10 homicides for every 100,000 citizens. Scotland is a distant second with a homicide rate that is only one-fourth of ours. 

Not all violence leads to death, of course: Violence destroys lives in a horribly versatile manner. For example, in addition to the 37,000 people killed annually by firearms, guns cause 100,000 devastating injuries such as brain damage or spinal cord injury every year.

Over the past 20 years, the violent crime rate has decreased slightly, but the rate of violent crimes perpetrated by and upon young people has shot up alarmingly. Injury and violence have replaced infectious disease as the chief killers of the young during the same period that the young have become responsible for a wildly disproportionate amount of violence and crime. The homicide rate among males 15-24 years old in the United States is 10 times higher than in Canada, 15 times higher than in Australia, and 28 times higher than in France or in Germany.  One in five violent crime arrests in 1994 were of someone under 18 years of age.

"We did have a skyrocketing of adolescent/young adult homicide rates, an epidemic that the biggest cities experienced first, in the mid-to-late 1980s," says Earls. "The second tier followed in the early 1990s. For example, Minneapolis saw its adolescent homicide rate double between 1987 and 1995. This is a real increase in adolescent violence, and we have learned to pay more attention to it." 

Easily obtained guns are an essential component of America's violent profile, especially for children, say experts. Shooting is now the chief cause of death for black teens and is second only to motor vehicle accidents in killing white teenagers. Firearms homicide for youths 15-19 years old increased 155 percent between 1987 and 1994. 

As a result of the shifting demographics of violence, the focus of research has shifted to the young. At the same time, the nation has fairly recently undergone a paradigm shift that recast violence, formerly within the purview of the criminal justice system, as a public health problem. In 1979, Surgeon General C. Everett Koop first included violence prevention as one of the nation's top 15 health priorities. Under the direction of Mark Rosenberg, the Centers For Disease Control and Prevention (CDC) promptly established its Violence Epidemiology Branch. The CDC organized symposia and conferences including the 1985 Surgeon General's Conference on Violence as a Public Health Problem. 

The story of how violence metamorphosed from a task for jailers and judges to a challenge for public health and medical professionals is closely intertwined with the efforts of a small group of pioneers on the faculty of the Harvard School of Public Health. They include Earls, whose meticulous, prospective studies ask: "Why do communities and their individual members differ so much in their crime rates?"; Professor Deborah Prothrow-Stith, a charismatic writer who clothes the insights of a clinician with the fervor of a proselyte; Professor David Hemenway, deputy director of the school's Center for Injury Prevention, who applies his expertise in economics to original investigations of firearm injuries; and Jay Winsten, director of the Center For Health Communication, whose "Squash It!" antiviolence campaign employs the same sophisticated social marketing strategies as his highly successful designated driver campaign that helped reduce drunk driving in the 1980s. 

Progress toward understanding a problem as complex and elusive as violence has been slow. "At the end of the 20th century, we are as close to understanding violence as we were to understanding medicine in the mid-1800s," observes Earls. But the extent to which we now define violence as a public health problem is illustrated by the fact that the very criminal justice and law enforcement proponents who once owned violence now call for partnerships with public health practitioners. In 1990, Lee Brown, police commissioner of New York, decried the city's record 1,905 homicides and called upon the medical profession to study the psychological and physiological roots and interventions, schools to educate children to violence prevention and churches to instill moral values that can discourage violent behavior. 

A single bullet changed the trajectory of Felton Earls' career, and, not incidentally, the way we view social science research, forever. Earls had graduated from Howard University School of Medicine in the late sixties and in 1968 was a postdoctoral fellow in neurophysiology at the University of Wisconsin at Madison. In April, he withdrew into a soundproof room for an experiment requiring that he remain isolated for several days. He emerged from his research cocoon into a transfigured world: The campus was in chaos because Martin Luther King, Jr., had been shot. 

Elegant neurophysiological abstractions were no longer an option, recalls Earls. "King's philosophy of nonviolence crystallized my interest in the issues surrounding violence and crime. My laboratory had to be the community, and I had to work with children because they represent our best hope.

Dr. Felton Earls, photo by Richard Chase

"I've always been interested in urbanization and health, and I see the planet becoming slowly urbanized in an irreversible way. It is a one-way process, and we're not very skilled yet in knowing how to build a healthy city. Where cities have the biggest social impact is on kids, so that's the reason I'm in public health."  

During the early sixties, crime rates had risen dramatically. More police were hired, more job training materialized, and more interventions and treatments were devised for delinquents and the criminally violent. But, says Earls, "The few intervention programs that looked at the outcomes beyond one year of ending the program have found that the effects wear off. In fact, the boys who received help had somewhat higher recidivism rates than the boys in control groups." 

By the late sixties, as crime continued to spiral out of control, researchers undertook retrospective studies, examining people who were already exhibiting violent behavior in an effort to identify predisposing factors. These retrospective studies fostered a post hoc ergo propter hoc mentality that long informed how policymakers looked at violence: Poverty, drugs, alcohol, associating with gun-toting friends, and even smoking came to be viewed as directly causative agents of violence. 

"The limitation of retrospective studies is that you identify people because they're already engaged in the outcomes you are predicting," explains Earls. "It's like loaded dice.'' Earls believes more subtle agents of destruction are probably at work, factors that will help explain why, even in the most destitute neighborhoods, only a small fraction of children and adults become violent. "As a scientist I have to say that we are largely ignorant of how and why people become violent. There's been a lot of work on antisocial behavior and violence, but nearly all criminal research to date has studied adults and older teenagers. By these ages, intervention may be too late." 

In March 1994, Earls launched a massive study that applies the rigors of prospective epidemiologic research to the multifactorial problems of violence and antisocial behavior. The Project on Human Development in Chicago Neighborhoods, sponsored by the John D. and Catherine T. MacArthur Foundation, the National Institute of Justice, the National Institute of Mental Health, and the Department of Education, will track 6,000 children in 80 Chicago neighborhoods until 2003 in an attempt to identify factors that risk violent behaviors. The study encompasses African-American, Latino, white and mixed ethnic neighborhoods, and all social classes. "By a detailed study of Chicago, we sample the whole universe of urban America," he says. 

"No other study has attempted to capture in a single design as much of the class and ethnic diversity of urban America. We're looking not just at how individuals shape their environments, but at how changing social and physical environments shape them." 

By studying human development in changing urban environments over time, Earls hopes to tease out the causes of antisocial behaviors such as violence and substance abuse and also to devise interventions and inform policy. Seven age cohorts of from 500 to 1,000 children are being followed over an eight-year period; by overlapping the cohorts, the study approximates 25 years of research. The study is unique not just for the number of people enrolled and the period of time looked at, but for the range of individual, family, and community variables being studied. 

"We start in childhood, much earlier than legal interventions, and we look at communities as well as family and individual effects,'' says Earls.  ³We plan to identify neighborhood influences that affect children for good or ill as they mature.... Many studies don't distinguish between witnessing violence and experiencing violence. They don't include sexual violence. I wanted to get a broad view of violence that could occur in family, home, and school. I think this is important because many studies specialized in one or the other and have not been in a position to answer questions about how they look when you combine factors. " 

The data gathering is proceeding rapidly, and although it's too early to analyze data, says Earls, "One interesting finding so far is that there are no poor white communities in Chicago. There are many poor white kids, but they're not concentrated in communities. They are distributed across working-class and mixed-ethnic neighborhoods. That alone tells you that the average poor white kid is growing up in better circumstances than the average poor black kid. The most common neighborhood in Chicago is a poor black neighborhood. This is a stark reality." 

But Earls is cautious about leaping to the conclusion that poverty per se is the root of all violence. "The fact that violent criminals and victims of crime are disproportionately members of minority groups is not strictly related to poverty,'' says Earls. ³It also has to do with the extent to which families and adults in a community monitor children in adolescence‹by setting curfews and having clubs and athletic facilities, so that adolescents have some positive activities. When a community deteriorates, the loss of supervision and opportunities for constructive activities may result in high levels of violence.''

In late January 1978, a decade after Earls emerged from his soundproof laboratory, a third-year medical student at Harvard was coming to terms with the strangely passive mentality toward violence adopted by her colleagues. On a stint in the emergency room during her six-week surgical rotation at Brigham and Women's Hospital, Deborah Prothrow-Stith saw, along with the sore throats, broken bones, and heart attacks, teens who were losing gouts of blood from knife and gun wounds. At 3 a.m. one night, a young man came in with a deep slash across his brow. ³If he'd been cut an inch lower, he would have lost an eye," recalls Prothrow-Stith. In the fast-paced milieu of the ER, she concentrated on her training, explaining as she sewed him up that she was suturing patients on her own for the first time. "He told me he'd been drinking heavily at a party, and he flared into anger at a comment from a guy he barely knew," she recalls. Insults flew, and an argument erupted, punctuated in blood when the other boy drew his knife. 

"After I stitched him up, he told me, "Don't go to sleep, because the guy who did this to me will be in here in an hour, and you'll get all the practice stitching you need." He delivered this with humorous bravado, and both I and the senior resident laughed. But later, it dawned on me that had he been joking about a suicide attempt, we wouldn't have laughed. In fact we would not have let him leave." 

Medicine appropriates everything: Why did doctors shy from treating violence as a medical problem, she wondered? "It's not because it's a complicated behavior: smoking, lead poisoning, tuberculosis are all complicated by social aspects and poverty," she says.

Dr. Deborah Prothrow-Stith, photo by Richard Chase

Prothrow-Stith says she felt from the first that the same public health strategies that had been so successful in curbing smoking and drunk driving could be employed to prevent violence. For her senior project, she wrote a curriculum for education in violence prevention under the supervision of Sandy Lamb, who went on to become Boston's deputy health commissioner. After she graduated in 1979, she got support from several quarters, including Boston City Hospital Chief of General Internal Medicine John Noble and Mark Rosenberg at the CDC injury center. Prothrow-Stith's senior project was the precursor to her Curriculum to Prevent Adolescent Violence that is now used in hundreds of schools internationally. David Nee at the Florence V. Burden Foundation funded writing of the curriculum. 

After Prothrow-Stith finished her medical residency at Boston City Hospital, she started a program for high-risk youth that became the Boston Violence Prevention Program. "When we first started, people thought we were a little odd because we treated violence in a health-care context. But early on, we saw that bad environments and substance abuse contributed heavily to the violent behavior we saw." Her anti-violence efforts attained higher visibility when, at 33, she became the youngest person--and the first woman--to serve as Commissioner of Public Health for Massachusetts. In 1990, she left the post to join the school's faculty, where, as Professor of Public Health Practice, she has continued her crusade to bring violence prevention within the rubric of public health. Her 1991 book Deadly Consequences combines anecdote and analysis to support the public health approach to violence. 

Prothrow-Stith feels that the efficient way to reduce homicide and assault is to focus on defusing the explosive scenario of two armed acquaintances seized by a sudden anger that is fueled by alcohol or drugs. The youth of those involved in killings, the fact that both the "aggressor" and the "victim" tend to be poor, of the same race, exposed to violence in the past, depressed, and know each other argues for treating both as victims, she says. "Each is likely to feel that fighting is his only choice," says Prothrow-Stith. Parents often abet this reaction by socializing children to feel that it is somehow shameful to walk away from a fight. "Children are not to be blamed for their inability to handle anger in non-lethal ways," she says. "We as parents, as teachers, as clergy, as health-care providers have failed to teach them this basic skill.... I think the outcome of violence is determined by environmental, cultural, and social factors: Kids learn to use violence." 

She points to the shocking figures on gun-toting students as evidence of kids' vulnerability. "Rarely have I heard of an adolescent who is carrying a gun for reasons other than protection. Inside, kids carrying guns do not feel strong: they feel weak and vulnerable. The gun they carry is their compensation." 

How does she answer those who suggest that violent urges lie in the genes and thus are not amenable to social programs or medical intervention? "The problem with such research is that there are such wide discrepancies in the homicide rate from country to country. That makes it hard to ascribe a biologically determined genetic function. If there were a small increase, you might be able to attribute to some predisposition. But when the U.S. rate is 70 times higher to 110 times higher, at some point we have to say ŒStop looking for a genetic focus and concentrate on social and cultural factors.' We haven't had a homicide in a child under 16 in Boston for 18 months, and while Boston is an interesting city, we certainly didn't change the gene pool."

Nowhere is the peculiarly American ambivalence toward violence more evident than in the issue of guns. Estimates place the number of guns now circulating in the United States at over 200 million--nearly one for every man, woman, and child. With so many firearms so readily available, it's not surprising that gunshots are the leading cause of death for black teens‹and the second leading cause of death for white teens. 

"Day after day, 100 people die from guns--and half of these are suicides. Clearly it's an American problem. Almost no other countries allow handguns for personal enjoyment," observes David Hemenway, deputy director of the Injury Prevention Center and professor in the Department of Health Policy and Management. Hemenway, an economist, points out that there has been relatively little research on guns given their public health importance. Accordingly, he has become something of a one-man firearms think tank, investigating who owns and carries guns and why; how to improve storage practices; the costs and benefits of gun ownership; the use of guns in self-defense; gun use among adolescents, on college campuses, and in suicide; and who belongs to the National Rifle Organization. 

Hemenway has found, for example, that men are more likely to own guns than women, Republicans are more likely to be armed than Democrats, and whites are more likely to pack firepower than blacks. Despite conventional wisdom, gun owners who have had firearms training are more likely than others to be among the 1 in 5 who store guns loaded and unlocked. "We've assumed that suicide, homicide, and accidental gun injuries were reduced by training," notes Hemenway, "but training seems associated with poor storage habits."

Dr. David Hemenway, photo by Richard Chase

Most recently, Hemenway and Professor Robert Blendon analyzed two decades' worth of public opinion polls that suggest the American ardor for firearms may have cooled: Gun ownership declined from 48 percent of households in 1973 to 41 percent in 1994. But, says Hemenway, this promising trend is tempered by the finding that even while shotgun and rifle ownership dropped, handgun ownership rose from 13 million to 24 million households during that same period. Not surprisingly, this increase in handgun ownership has been concomitant with a marked increase in violent crimes. There were 417 crimes for every 100,000 people in 1974, but this rate leapt to 746 in 1993. 

Much of the gun-control debate still takes place in the law-enforcement arena, but in 1986 public health physicians declared gun ownership a "public health emergency," and the Journal of the American Medical Association issued recommendations for stricter gun control measures, citing not only the 38,000 Americans killed by firearms but the 90,000 gun injuries treated annually in hospital emergency departments. 

The rise in handgun ownership may be disquieting, but what does augur well is the discovery that 90 percent ofAmericans‹including gun owners‹believe that guns should be withheld from youths under 18 and from those with criminal records. Eighty-six percent of Americans support the Brady Act that includes a 5-day "cooling-off" period and provision for background checks on those who wish to purchase guns. The public also supports the limit of one handgun purchase per month and a ban on assault weapons. 

Hemenway's research supports Prothrow-Stith's claim that children carry guns for defense. He has found that knowing victims of violence, being threatened with a gun, having friends and family who have guns or are involved in drugs are all associated with a child's gun carrying. Yet 87 percent of children surveyed say they want to live in a world with fewer guns and 76 percent, including more than half of adolescent gun carriers, want it to be impossible to obtain guns. "Currently, it's easy," adds Hemenway. 

"We're now looking at a contagion mode in which people feel less safe as their neighbors or classmates acquire guns. This causes them to acquire guns in response," he says. Everyone falls into a category‹susceptible, infected, or resistant. Just as with TB, isolating and treating a few "carriers" may have profound health advantages; Hemenway's studies suggest that training in conflict resolution and open family discussions may protect children from catching the handgun "bug." 

"This is such a contentious area. It is hard to research, because the NRA is attacking the CDC for giving money to gun research. Gun-control critics claim guns are more often used in self defense than in crime, but our surveys show this is not even close to the truth." Other studies find it 43 times more likely that a gun in the home will kill someone who lives there than an intruder, and that guns in the home also increase the likelihood of suicide. "The NRA says public health people are opposed to all gun ownership," says Hemenway. "I'm not. I advocate more rational gun policies."

One of the important strengths of Harvard's violence-prevention strategies is the cooperative nature of faculty efforts. Their diverse approaches often converge synergistically. For example, Prothrow- Stith and Earls have taught a course, "Violence in America," for several years. "I am the scientific presenter about causation," says Earls, "and Deborah brings an interventional and therapeutic approach. We constantly have crosstalk about what we know from social and behavioral sciences and how that relates to prevention." David Hemenway is now collaborating with Earls' study, helping his groups to better assess injuries that stem from violence.

Jay Winsten, director of the Center For Health Communication, also lectures to the violence class. And he literally got a hand from Earls in designing his nation-wide Squash-It! violence prevention media campaign.  "I was discussing with Jay work on nonhuman primates showing conflict avoidance," recalls Earls. "Gesture is extremely important in getting a creature to back off. This got Jay and me to talking about incorporating the 'Squash It!' hand signal with his verbal message."

Despite the large gaps that still exist in understanding how and why violence occurs, the school's experts express optimism that a multifaceted approach from public-health practitioners, schools, parents' groups, the churches and law enforcement will continue to reverse the deadly trends. Prothrow-Stith predicts that parents' groups such as the National Coalition of Survivors for Violence Prevention will have the impact of Mothers Again Drunk Driving. "I find the activism of survivors of violence very exciting," she says.

As of March 1997, Boston had seen no homicide involving a minor child for eighteen months. ³I don't think this is an artifact,'' declares Earls. ³It's a real effect that demonstrates something. What happened here is that many parts of the community--police, schools, after-school programs--all combined. But it's easy to back off. If that happens, I expect violence rates to rise again."

 

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